Intravenous (IV) fluid prescribing is a common occurrence in general medical wards and it is often the most inexperienced, junior members of the clinical team who are responsible for assessing the need for fluids and determining the composition and rate of fluids prescribed. Inappropriate fluid prescribing leads to increased morbidity and mortality.
The project involved assessing how closely NICE guidance (CG174) on fluid prescription was being followed by medical teams at a busy district general hospital. Teaching sessions and educational resources were implemented across the Trust to promote awareness of the issues surrounding fluid prescribing and improve adherence to guidance.
Co-Authors: Dr David Cunningham(FY2), Dr Omer Husain( FY2), Consultant Dr Samuel Sanmuganathan, Consultant Dr Mike Hayward, Isla Mcdonald (Patient Safety Nurse) and Catherine Plowright, Consultant Nuse in Critical Care.
Example
Aims and objectives
The project aimed to assess how closely NICE guidance on fluid prescription in adults was being followed by medical teams at a district general hospital.
Objectives included:
- To promote awareness of NICE guidelines on fluid prescribing
- Identify specific aspects of NICE guidance that are being followed
- Identify specific aspects of NICE guidance that are not being followed
- Identify reasons why aspects of the NICE guidance may not be being followed
- Implement changes to improve adherence to NICE guidelines
Reasons for implementing your project
Since starting work at the hospital and looking after patients in a variety of clinical settings we came across several cases where patients had been affected as a result of poor fluid management, with patients often being under-resuscitated, having inadequate maintenance fluid prescribed or developing complications of fluid overload.
There was no quantitative evidence to support this at our hospital at this point. Research showed that this was not a problem limited to our trust and poor documentation of fluid balance and unrecognised fluid imbalance has been shown to impact patient morbidity and mortality. (NCEPOD report 1999, updated 2011).
We performed a baseline data collection and subsequently conducted two PDSA cycles which followed interventions aiming to improve adherence to NICE guidelines. Analysis of baseline data demonstrated that none of the NICE criteria were met with 100% adherence. Furthermore, in only 2 out of the ten cases was adherence of greater than 60% noted.
Through discussion with other doctors, including consultants we recognised that it was often the most junior members of the team (foundation doctors) who dealt with fluid assessment and prescription. We therefore felt that interventions aimed at improving junior doctor education were key. We were then faced with the problem of changing the prescribing habits of junior doctors. Achieving this was difficult and a slow process, but through conveying our message in different formats over a period of several months we were able to make a significant change.
How did you implement the project
We performed a baseline data collection and two subsequent PDSA (Plan, Do, Study, Act) cycles which followed interventions aiming to improve adherence to NICE guidelines.
Each round of data collection involved reviewing patient ward notes and drug chart on three of the acute medical wards. A proforma was completed for each randomly selected patient on the ward to determine whether each of 10 chosen NICE criteria was adhered to.
Following baseline data collection, teaching sessions were delivered to junior doctors. Teaching at these sessions covered all aspects of NICE guidance and composition of commonly prescribed fluids with emphasis on the monitoring and assessment for patient requiring intravenous fluids and early switch to oral fluids if patients start eating and drinking. A further set of measurements was then taken (PDSA 1, n=20). Educational posters were placed on medical wards prior to PDSA 2 (n=40).
The 10 NICE criteria under consideration were as shown in the table below:
|
NICE rec by number |
NICE Criteria |
Standard |
Adhernece Target |
|
5 |
Did the patient have an IV fluid management plan? |
Patients should have an IV fluid management plan |
100% |
|
6 |
Did the IV fluid management plan include the fluid and electrolyte prescription over the next 24 hours? |
Fluid management plan should include fluid and electrolyte prescription over the next 24 hours |
100% |
|
7 |
Did the IV fluid plan include the assessment? |
Fluid management plan should include an assessment |
100% |
|
8 |
Did the Iv fluid management plan include the monitoring? |
Fluid management plan should include monitoring |
100% |
|
12 |
Did the patient receive fluid resuscitation? |
Where indicated patients should receive fluid resuscitation |
|
|
13 |
Was the patient reassessed after initial resuscitation? |
Patient should be reassessed after initial resuscitation |
100% |
|
14 |
Was the patient reassessed using the ABCDE approach? |
Patient should be reassessed using ABCDE approach |
100% |
|
23 |
Did the initial prescription include no more than 25-30 ml/kg/day of water? |
Initial prescription should include no more than 25-30 ml/kg/day of water |
100% |
|
24 |
Did the initial prescription include approximately 1mmol/kg/day of K+, Na2+ and Cl-? |
Initial prescription should include approximately 1mmol/kg/day of K+, Na2+ and Cl- |
100% |
|
25 |
Did the initial prescription include approximately 50-100g/day of glucose? |
Initial prescription include approximately 50-100g/day of glucose |
100% |
Key findings
Analysis of baseline results demonstrated that the approach to IV fluid prescribing was highly variable with poor awareness of NICE guidelines. This was gauged by determining the percentage of patients where each of the given NICE criteria were met.
None of the 10 criteria were met by 100% of patient cases (N=20) with results ranging from 10% of patients cases (Criteria number 25) to 65% of patient cases (Criteria number 23). The mean adherence was 49%. A cycle was repeated following teaching sessions delivered to junior doctors and repeat measurements showed no improvements initially. In this cycle (N=40) mean adherence was 68%.
A further analysis was conducted following a second intervention in the form of educational posters that were placed on medical wards for several weeks prior to the analysis.
For each of the ten criteria the percentage of cases where the criteria were met was increased (N=20, mean adherence 71%). Thus we concluded that an improvement had been made. Whilst improvement was evident, 100% adherence was not observed.
We have therefore implemented a further intervention in the form of informative lanyards which have been produced and have been distributed to junior doctors. Ongoing rounds of analysis will be performed after implementation of this change and the project has been taken up by new junior doctors on a rolling basis.
Key learning points
One of the key points that we took away from this experience is to take a considered approach when determining interventions.
As a team, through discussion with consultants and other members of the medical MDT we determined that the best approach would be to target junior doctors. We therefore were able to take a focussed approach that we felt would lead to improvements.
Secondly, we would advise that if an intervention doesn’t lead to improvement then don’t be put off. In our case the first intervention did not lead to any improvements as the teaching sessions were not particularly well attended. Performing multiple PDSA cycles allowed us to re-analyse our approach and consider a new intervention with the aim of seeing overall improvements in adherence to guidelines.